Provider Demographics
NPI:1174051346
Name:PRO BRITE DENTAL
Entity type:Organization
Organization Name:PRO BRITE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:QUYEN
Authorized Official - Middle Name:LE
Authorized Official - Last Name:TRAB
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:781-780-5234
Mailing Address - Street 1:948 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:02149-3128
Mailing Address - Country:US
Mailing Address - Phone:781-708-5234
Mailing Address - Fax:
Practice Address - Street 1:948 BROADWAY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:MA
Practice Address - Zip Code:02149-3128
Practice Address - Country:US
Practice Address - Phone:781-708-5234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1855435261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental